You did what???

by Bob Stuntz

Hey everyone.  First, just wanted to say sorry for the 2 week or so absence.  My wife and I just recently had our second child, and between going back to work after paternity leave and not sleeping, I’ve been a bit preoccupied.  I’m back on a better schedule now, so thanks for your patience and understanding.  The next podcast, part 2 of the RUSH exam, should be out in the next few days.  

I recently was told of a case that got me thinking.  The situation and names have been changed to protect the innocent, or guilty as it were.  A young man presented to an ED with a foreign body that was, lets say, stuck on a very sensitive part of the body.  When he showed up, it had been on for a few hours.  He was in extreme pain.  A medical student picked up the case, and with the nurse, took it upon themselves to remove the foreign body, under the guise that it was “limb threatening” (At least I’m calling it a limb).  This was done without any attending or resident supervision.  Furthermore, the patient had no idea this was a student.  Fortunately the offending agent was removed, and the patient did well.  

As a medical student, or a junior resident, it can be tempting to take something like this on by yourself.  In a competitive world of residency and job applications, you want to stand out and look like a star.  The thought of doing a procedure on your own that saves a life or limb is tempting, and I can see how someone would want to impress their residents, upper levels or attendings.  You don’t want to be seen as passive.  You want to be aggressive, see patients, do procedures, and impress those around you while learning at the same time.  

I also remember the feeling as a med student of being the “third wheel.”  You do not want to bother people who are already busy, and you do not want the people you are trying to impress thinking you are needy.   But remember, being a cowboy and doing it on your own can backfire in a major way.  

First, most medical students are doing rotations at academic institutions, or institutions where at the very least the attendings want to work with medical students.  Obviously, if you are a resident, your attendings want to teach.  Teaching is what we are here for, and we will always take an interruption to help perform a  life or limb saving procedure.  We expect you to come to us.  

Second, even if you perform the procedure successfully, some people will see you as reckless, someone who is willing to take big risks and feels like they do not need help.  This makes it less likely down the road that you will be sought out for procedures.  

Third, we have a tough job in the ED.  We have a few minutes to inspire confidence and trust in our patients.  If a paint has something done under the presumption that a doctor is performing a procedure, or you do not fully inform them of your title and role, this can cause a serious amount of distrust if the patient discovers a student was doing an unsupervised procedure.  This puts the student at a disadvantage, as we already know patients are reluctant to have students perform procedures to being with.  

Finally, and most importantly, there is the risk to the patient.  Your job as a physician and student physician is to always take the best care of the patient possible.  You may think you know what you are doing and be completely wrong, or you may know what you are doing and have a bad outcome.  Regardless, you need to be directly supervised when performing any procedure unless told otherwise.  

So what is a student, or junior resident, to do?  Observe the following rules:

1. Err on the side of caution.  If you have any doubt as to what you are doing, or any question about the care you are providing, get help.  

2.  Don’t worry about appearing weak.  We want you to come get help in a critical situation.  We want to be involved, and we want to teach you.  

3.  Do not sit on critical patients.  Get a senior or attending involved early.  If you feel you cannot leave their side (i.e. performing CPR), send someone to get help.  

4.  Be aggressive, but know your limits.  If you have a question, run it by a senior.  ”This patient is tachycardic and borderline hypotensive, is it ok if I go see them, or do you want to see them with me?”

5.  Do not do any procedure without at least discussing it with someone senior to you.  

And finally, but informally, if a hacksaw is involved, you definitely should not be doing it on your own!